Voices of families need to be considered in debate to reform state's Medicaid behavioral health system

Some of the voices least heard in the discussion to privatize the Medicaid-funded behavioral health system in Michigan or improve the current system are the families of those 350,000 people with mental health problems, substance abuse addictions or the intellectually or developmentally disabled.

I sat down recently with 10 family and board members of the Alliance for the Mentally Ill Oakland County in Southfield. For more than 90 minutes, they told me difficult stories about their sons, daughters and close relatives, and how they have passionately fought to maintain or expand services to make better the lives of their loved ones.

Quite honestly, they could have talked longer if I had not interrupted them, sometimes abruptly, because I wanted to know why, if they sometimes have problems under the current state system, they are so vehemently opposed to having Medicaid health plans manage the $2.6 billion Medicaid behavioral health funds, as Gov. Rick Snyder has proposed and state legislators appear to be carrying out in the fiscal 2018 budget.

Fred Cummins, chair of the AMI Oakland County board, gave me a straightforward answer.

"If we think it is bad now, wait until the HMOs start making decisions," said Cummins, who earlier spoke about his 50-year-old daughter who has suffered from a form of schizophrenia since age 17. "We are taking care of her now."

Cummins then described in a two-page letter he handed me how his daughter had been denied necessary support services by mental health agencies that affected her health and nearly killed her, he said.

In a statement, Cummings said the following: "(The) community mental health and the core provider have, through their misconduct, been reward by saving hundreds of thousands of dollars in addition to costing taxpayers hundreds of thousands of dollars in physical health care services."

Despite having problems ensuring his daughter has sufficient mental health services through the current system, Cummins is very much opposed to the effort to transfer Medicaid behavioral health system to the management of the 11 Medicaid HMOs.

I have to say at this point that I understand their frustration with the current system, and I understand they have extreme worries about moving to an unknown system run by HMOs, half of them owned by out-of-state for-profit companies.

Believe me, I have covered health care for 35 years, and I recall writing stories in the 1980s and even in the 1990s about how health insurers and HMOs, more often, denied physical health care to people that led to their deaths. It happens.

My friend, Wendell Potter, a former Cigna executive, whom I used to interview when I was with Modern Healthcare, a sister publication of Crain's Detroit, also has told me horror stories about HMO denials and their profit motives.

I also must say that I have covered Michigan's now 17 HMOs since 2008. There has never been an egregious case brought to my attention like those I have covered in the past.

Do HMOs and insurance companies deny and delay coverage? Yes, of course they do. Complaints are filed daily with the state Department of Insurance and Financial Services. It has happened personally to me and I have unsuccessfully complained. But those instances were about minor issues involving what is a covered service or whether a charge should be considered under dental or medical deductions. Not about the life-threatening issues facing these families who depend daily on mental health workers.

However, I do believe the Medicaid HMOs in Michigan are doing a better-than-average job than others nationally. Not perfect by a long shot, especially on the behavioral health side, where statistics are nonexistent or below average. The National Commission on Quality Assurance bears out that statement. Look at the statistics. Michigan HMOs do pretty well comparatively in the NCQA's annual ranking of health plans. For example, six of the state's 11 Medicaid HMOs ranked in the top 50 nationally.

But concerns about Medicaid HMOs managing behavioral health, substance abuse and also care to those people with intellectual and developmental disabilities are real to the families.

While there is a national trend toward handing over Medicaid funding to managed care organizations to dually manage physical and behavioral health — under the goal of care coordination and reduced costs — the results so far are uneven and the theory so far is unproven, in my opinion.

For Crain's, I have written about integration of physical and behavioral health, and none of the 31 states can absolutely prove they have a successful model. I wrote a Health Care Extra package of stories in May 2016 that looked at the issue and the three states experimenting with integration.

Maybe Michigan can figure it out, but the track record so far is thin for positive results.

This is why families like Bob and Judy McReavy are so concerned. The McReavys have a son with mental health problems who lived independently for 30 years. That changed recently when the state began cutting budgets the last three years for a total of 17 percent at the Macomb County Community Mental Health Authority, which had to cut downstream costs.

"He is back at home," Bob McReavy said. "Gov. Snyder and the legislature are hurting the disabled with budget cuts. He got treatment costing $1,800 per year with a $4,200 housing subsidy. Budget cuts close the (independent housing program in Macomb County) and 30 people lost housing."

Bob, who became visibly upset as he spoke to me, said his son has been hospitalized three times this year.

"He was so sick he almost died. So far the court-ordered hospitalizations cost $180,000. Where is the savings? This budget cut has created more homeless people."

Judy McReavy said she believes more cuts will occur if Medicaid HMOs manage the behavioral health budget.

"We know what will happen ... when the HMOs get the money," said Judy McReavy, her voice shaking. "The money has been cut; services have been cut. There is a mental health code. HMOs won't follow the code and nobody will enforce it."

Bob added: "HMOs are third-party profiteers. They present an illusion of programs that is another money grab."

Before I left the meeting, Bob handed me a statement that said the following: "I am afraid to die and leave my son at the mercy of a broken mental health system, a system designed to fail. I am afraid to die and leave my son at the mercy of five insurance companies that are profit-driven."

Another AIM board member, Cheryl Patel, talked about how she has had become very loud to get necessary services for her 42-year-old daughter.

"She first came down with (psychosis) when she was 20. She struggled. I know what rights are because I asked for them. She wouldn't have been helped if I didn't (plead) for them."

Patel said now her daughter lives independently and has community living services workers check on her every day to make sure she is taking her medications and has no problems. "I worry about her all the time," Patel said.

George Martin, a Russian immigrant also on the AMI Oakland board, also worries about Medicaid HMO management reducing services for his nephew, who he has been the guardian for the past 20 years.

"He is in a group home now and is well taken care of," Martin said. But he is concerned that if Medicaid HMOs make decisions, all will change. "HMOs, they are big companies like General Motors. They are looking for the money," he said.

Dick Berry's son was at Clinton Valley Psychiatric Hospital for years with a schizoaffective disorder before the hospital closed in 1997.

"He has his own apartment now and is semi-independent," said Berry, noting that Easter Seals provides good care for him in Oakland County. "I have not had any problems with my son. He is quite independent."

But Berry — like all the others who told me their stories — worries Medicaid HMOs would cut services and he would slide back into poor health.

Marjorie Mitchell, executive director of Michigan Universal Health Care Network and a longtime advocate for mental health, said many families are concerned because the state's Medicaid behavioral health system has been underfunded for years.

"In many instances the system is working. There are still lots of problems. But why throw it all out and try an untested system?" Mitchell said. "(Families) have watched over the years as the state Legislature and federal government cuts funds, often on backs of people with disabilities."

Mitchell said families want to fix the current system and fund it correctly before making plans for wholesale changes.

Besides Mitchell, some of the others at the meeting were professionals, either retired or still working in the mental health industry. I asked them: So what should the state do?

One idea they have is to eliminate all 10 regional prepaid inpatient health plans, which manage Medicaid funding on a regional basis for the state, and allow the state Department of Health and Human Services to contract with mental health agencies and monitor compliance. Three PIHPs are in Wayne, Oakland and Macomb counties.

"There is no need for PIHPs. Take them away and you have one less layer of bureaucracy," said Elizabeth Bauer, former state education board member and former director and founder of the Michigan Protection and Advocacy Services.

Bauer suggested to former Gov. Jennifer Granholm in 1996 that the state should create a contract and compliance unit within MDHHS. Instead, Granholm and the state Legislature initially created 18 PIHPs, which were later consolidated to 10.

"No governor wants to add state employees, but my proposal was to form a contract management and compliance unit and that unit would contract with the 94 core providers," said Bauer.

Mitchell said the governor could appoint a nine-member independent commission to oversee the state's mental health system. The commission would ensure quality is maintained with the contracts.

"I think there needs to be an independent recipient rights department to take complaints and make sure complaints get resolved," Bauer said. "Most people now who file a rights' complaint are not satisfied with the investigation and resolution."

Bauer said funding issues could be better addressed if the budgets for education, mental health and corrections were developed in an integrated fashion with the targeted population in mind.

"Budgets need to be developed collaboratively so education is not paying for the same thing as (mental health) and corrections," said Bauer, who has a 50-year-old daughter who was born deaf with profound developmental disabilities and often had duplicated services and providers. "If we did it right, we would save money and provide better services."

As part of the effort early last year by Lt. Gov. Brian Calley to slow down Gov. Snyder's plan to privatize the Medicaid behavioral health system, a Section 298 Workgroup was formed to study the issue. The workgroup contained a cross-section of affected parties, including Medicaid health plan representatives.

But one of the chief complaints families and advocates have is that the Section 298 Facilitation Workgroup Report, which developed recommendations to improve the current behavioral health system, did not persuade Republican state legislative leaders to act on them into the state budget proposal. Instead, legislators want HMO pilot programs to test integration.

Nick Ciaramitaro, former Democratic state legislator for 19 years from 1978 to 1998 and now director of legislation and public policy of Council 25 AFSCME Michigan, said most families have three main concerns about the proposed legislative changes.

First, that Medicaid HMOs would be responsible for the care; second, that the HMOs would cut services to boost or maintain profits; and third, accountability to families and clients would be lost, he said.

"People now can go to (the) Macomb County board" with problems or appeals, said Ciaramitaro, who also is on the board of the Macomb County Mental Health Authority, one of the 10 PIHPs.

"You can't go directly to HMO board to complain or appeal" because they either are out of state or don't have regular meetings. "HMOs are only accountable to shareholders. It is different when you go talk with someone you know."

I reminded the families that Medicaid HMOs have state contracts and must follow a specified multi-step system to deliver services and address and resolve physical health complaints. All families scoffed at the possibility that complaints would be corrected.

"Right now we have a Medicaid transportation system that doesn't work," Mitchell said. "People have missed surgeries and specialist appointments because drivers aren't there. We are complaining about this now" to force the state to enforce the rules.

But the $2.6 billion question is what Michigan Republicans will do about reform proposals. They will soon be voting on a $55 billion-plus state budget that will have the boilerplate language that could lead to massive changes in the current Medicaid behavioral health system.

Will they adopt a proposal to create a single statewide PIHP, as one boilerplate suggests? Will they adopt a provision to conduct a pilot study in Kent County — and possibly two other regions — to integrate physical and behavioral health?

Or will they adopt language that could lead to the complete privatization of the Medicaid behavioral health system by 2020, as Sen. Mike Shirkey of Clarklake wants?

"I am hearing a number of Republicans are uncomfortable with the approach," said Ciaramitaro, adding: "The boilerplates could be modified or rejected. All you need is eight to 12 votes to stop the budget."

But state Rep. Laura Cox, R-Livonia, chair of the House appropriations committee, sent this letter out recently to a voter and constituent, expressing her desire to develop pilot programs to test how well Medicaid HMOs manage behavioral and physical health.

"Our ultimate goal is to move toward a better standard of care for the people of Michigan. We believe our proposed budget does that by combining the management of behavioral and physical health services. One of the proposed changes is to consolidate the 10 regional PIHPs into one statewide PIHP. This would provide a more uniform way to deliver services, while also cutting away at excessive administrative spending so we can invest more in our service recipients.

"We are also proposing a pilot program in Kent County that would allow the PIHP and Medicaid health plans to delegate certain managed care functions and transfer accompanying state funding to a provider network that would then manage care.

"This model would require the PIHP and the Medicaid health plans to take a step back and allow the providers who work more closely with individuals who receive services including the (community mental health service providers), to provide managed care and services," Cox wrote in her letter.

I am not sure what the Republicans will ultimately do. The Democrats want to improve the current system. I have heard loud and clear what the families want.